Determinants of sleep quality among pregnant women in a selected institution in the Southern province, Sri Lanka

Background Sleep is a vital requirement during pregnancy for the betterment of the fetus and the mother. Sleep quality could vary due to pregnancy-specific psychological and physiological changes. To introduce a tailored programme to enhance the sleep quality of mothers, it is paramount to assess the sleep quality and determinants of sleep. Therefore, this study aimed to assess the determinants of sleep quality among pregnant women in a selected institution in the Southern province of Sri Lanka. Methods Hospital-based cross-sectional study was carried out with 245 antenatal women, selected using a systematic random sampling method. A pretested self-administered questionnaire was used to collect data which contains four parts. Below variables were involved and both continuous and categorical data were collected as required. ‘Maternal sleep quality, socio-demographic data and gestational age, maternal depression and anxiety.’ Data were analyzed using IBM SPSS version 25.0 for Windows by using descriptive statistics, Pearson’s Chi-square test, and independent sample T-test (p < 0.05). Logistic regression analysis was used to find the relationship with sleep quality and other variables. P-value of less than 0.05 was considered statistically significant, at 95% CI. Results The majority of women (60.8%) had good sleep quality and they didn’t have either depressive symptoms (63.4%) or anxiety (64.2%). Aged between 34–41 years and third-trimester women had higher rates of poor sleep quality. Varying quality of sleep was identified among three-trimesters with subjective sleep quality, sleep latency, habitual sleep efficiency, and sleep disturbances. In comparison with the first and second trimester, pregnant women in the third trimester had higher score of global PSQI (5.22 ± 2.35), subjective sleep quality (1.23 ± 0.70), sleep latency (1.25 ± 0.86), habitual sleep efficiency (0.14 ± 0.43), and sleep disturbances (1.39 ± 0.58). There was a significant association between gestational age (P = .006), maternal age (P = .009), antenatal depression (P = .034), and anxiety (P = .013) with sleep quality. However, multinomial logistic regression revealed that only gestational age affected on quality of sleep. The first trimester was a protective factor for good quality sleep (Adjusted OR = 3.156) compared to the other two trimesters. Conclusion This study revealed that the majority of women had good sleep quality but quality of sleep was deprived with gestational age. It is expected that the findings of this research will be helpful for health and social care policymakers when formulating guidelines and interventions regarding improving the quality of sleep among pregnant women in Sri Lanka.

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Introduction
Sleep is one of the most important basic needs of the human being which helps to maintain metabolic activities effectively [1].Sleep quality is a measurement of indicating how well people are sleeping.Basically, there are four elements use to measure sleep quality such as sleep latency, sleep waking, wakefulness and sleep efficiency [2].Pregnancy as a unique period of a woman's life hence quality sleep is an essential requirement for a healthy pregnancy to conserve energy for delivery process with 7 -9 hour sleep [3,4].
Typically, pregnancy creates significant physiologically, anatomically and biochemically changes, and these changes may affect physically and emotionally to the women's life which leads to sleep disturbances [5].Enlarging abdomen, heartburn, frequent movements of the fetus are more commonly affect to each trimesters can be the reasons for a frequent awakening from the sleep and poor sleep quality of a pregnant woman [6].Also the relationship between sleep quality and psychological disturbances can cause to maternal morbidity and neonatal birth complications [7].
There is dearth of studies have been conducted about sleep quality among pregnant women in Asian countries including Sri Lanka.A China study reported that 87% mothers experienced sleep disorders during pregnancy period while prenatal depression, age and gestational age had found as contributing factors for the sleep quality [5].The studies done in other countries reveal higher prevalence of poor sleep quality and similar results has found as above study [8,9].Further, none of the reported studies in the south Asian region had compared the difference in sleep quality among 3 trimesters and neither of them had identified associated factors for the poor quality of sleep during each trimester.Therefore, objectives of this study were to determine prevalence of poor sleep quality, identify factors associated with poor sleep quality, compare the difference in sleep quality among three trimesters and identify the psychological disturbances encountered with pregnant mothers due to poor sleep quality in Teaching Hospital Mahamodara (THM), Galle.

Study setting and study population
A Hospital-based descriptive cross-sectional study was carried out in antenatal clinics and antenatal wards at Teaching Hospital Mahamodara.The study population consisted of all pregnant mothers who were registered in THM.

Eligibility criteria
Pregnant women who could understand Sinhala or English and who were willing to participate were included to the study after provide detailed information and take the consent.Pregnant women who were not willing to participate and who had severe psychiatric illnesses were excluded from the study.

Sample size determination and sampling procedure
The sample size was calculated by using the formula suggested by Lowanga & Lameshow in 1991 with 1.96 as standard normal deviation for the chose confidence level, 83% as expected proportion of subject with characteristics, based on the research study of public health center in Yogyakarta, Indonesia [1] and another research study of determinants of sleep quality among pregnant women in China [5].Accordingly, the required sample size was 217.
A further adjustment to the sample size was made considering non-response or incomplete response rate of 10%, making the final sample size 242.Simple random sampling method used to select mothers from antenatal wards and antenatal clinics by taking a list of all mothers from the register of the particular antenatal ward or clinic and selected the individual who belonged to the even number.

Data collection and management
A self-administered questionnaire which contained four parts were used to collect data.These parts were pre-tested self-developed questionnaire to assess socio-demographic details.
Validated Sinhala versions of Pittsburg Sleep Quality Index (PSQI) to collect data related to sleep quality, Edinburgh Postnatal Depression Scale (EPDS) to screen depression in antenatal women and Generalized Anxiety Disorder 7 scale (GAD-7) to screen anxiety level.The average duration of the questionnaire was 10 minutes.Informed written consent was taken after explaining the objective of the study.Ethical clearance was obtained from the Ethical Review Committee, Faculty of Allied Health Sciences, University of Ruhuna.

Operational definitions
'Sleep quality' was defines as an individual's self-satisfaction with all aspects of the sleep experience.'Maternal anxiety' was defined as a feeling worry, nervousness or unease about something with an uncertain outcome during pregnancy period.'Maternal depression' was defined as a mood disorder that causes a persistent feeling of sadness and loss of interest during pregnancy period.

Data analysis
Data was analyzed using Statistical Package for Social Sciences (SPSS) 25 version software.
Descriptive statistics such as mean (SD), median (IQR) and frequencies (%) used to describe level of psychosocial disturbances of study the participants.Normally distributed data was further analyzed for inferences, using ANOVA and independent samples t-test.Chi-square and correlation analysis were used to identify the associations between independent and dependent variables.P value less than 0.05 (p<0.05) was considered as statistically significant.

Results
Mean age of the pregnant women were 30 years.Majority of subjects were married, unemployed and education up to O/L with monthly income between 30,000 -40,000 rupees.
Most of the pregnant women were in the third trimester and primi mothers.Among the sample, most of mothers had children between 1 -3 children.Majority of pregnant women had single/separated type of house.Concerning the type of bed room, most of them had a separate bed room for sleep at night while the majority of mothers had high level of family support for their day to day works.Their mean BMI was 18.5 to 24.9 (Table 1). to the PSQI results.There were majority of pregnant women had taken less than 15 minutes to 143 fall asleep each night during the past month while most of pregnant women had more than 7 144 hours of sleep during the last month.145 Frequency distribution of sleep disturbances according to the PSQI showed that 146 majority of participants had disturbed sleep three or more times a week due to wake up in the 147 middle of the night and get up to use the bathroom during the last month as well as most of 148 pregnant women had not any prescribed or over the counter medicines to help them in sleep.149 Daytime dysfunction over the past month according to the PSQI indicated most of participants 150 had not trouble with staying awake while driving, eating meals, or engaging in social activity 151 during the last month while 69% of mothers had not any problem to keep up enthusiasm to get 152 things done (Table 2 1).
Difference of sleep quality among three trimesters showed that pregnant women in third trimester had higher score of global PSQI, subjective sleep quality, sleep latency, habitual sleep efficiency, and sleep disturbances than first and second trimester.
When compared with third trimester, pregnant women in second trimester had higher score of sleep duration, habitual sleep efficiency and daytime dysfunction.There was no statistically significant differences across trimesters in the following PSQI component scores: sleep duration, use of sleeping medication, and daytime dysfunction (Table 3).Association of psychological disturbances and sleep quality shows that there was a significant association between antenatal depressions and anxiety signs with sleep quality during antenatal period (Table 4).

Discussion
Quality sleeping is a substantial requirement during the pregnancy to maintain physical, psychological well-being of a mother and well-being of the fetus.Therefore present hospital based, cross-sectional study was conducted to determine the prevalence of poor sleep quality, compare difference of sleep quality in each trimester, psychological disturbances and other factors affecting for sleep quality among antenatal mothers.
In the current study, the mean age of years was comparable with several other studies carried out in developing [10] and developed countries.The monthly family income of majority of mother was lower (<LKR 50,000.00)than the nominal Sri Lankan mean house hold income of LKR 62237.00[11] which may be attributed to the fact that most women in the study were unemployed.Nordic Sleep Questionnaire to collect data [12].The plausible explanation may be that the participants in these studies were in similar age category, economical studies and BMI level as important parameters.
Sleep quality can be affected by several factors.In a more recent study in China has reported that increased maternal age and gestational age are important determinants of sleep quality [5].In present study, above factors were also identified as determinants.However, another, Ethiopian study has found multiparity as another determinant addition to the above factors [8].Cultural differences of two countries may be the reason for this difference.Cultural differences of two countries may be the reason for this difference.
Quality of sleeping also varying within three trimesters of pregnancy due to The strength of our study is provide more detailed information to explain sleep quality with efficiently using limited amount of cost.Maintain anonymity and selfadministered questionnaire might have promoted the honesty of the answers.To our knowledge, there is no other published research about this study area in Sri Lanka.However, limitations of the study should have been acknowledged.Though, the analyzed data are derived from a self-administered questionnaire, some questions had to be explained to some mothers.
It could be the cause of recall bias.Though, validated questionnaires are limited in Sinhala language, study group always use the pretested translated questionnaire to minimize the effect of this limitation.Further, in this study it was not assess how disease conditions affect to the sleep quality during pregnancy period due to limited time and practical constrain.

Conclusions
This study showed, the prevalence of poor sleep quality among pregnant women was 39.2%.Advanced maternal age, gestational age, prenatal depression and anxiety were predominant determinants of sleep quality during pregnancy period.Good sleep quality had gradually decreased from first trimester to the third trimester.Women in third trimester with the following details: Initials of the authors who received each award • Grant numbers awarded to each author • The full name of each funder • URL of each funder website • Did the sponsors or funders play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript?• Did you receive funding for this work?Competing Interests Use the instructions below to enter a competing interest statement for this submission.On behalf of all authors, disclose any competing interests that could be perceived to bias this work-acknowledging all financial support and any other relevant financial or nonfinancial competing interests.This statement is required for submission and will appear in the published article if the submission is accepted.Please make sure it is accurate and that any funding sources listed in your Funding Information later in the submission form are also declared in your Financial Disclosure statement.View published research articles from PLOS ONE for specific examples.The authors have declared that no competing interests exist.NO authors have competing interests Enter: The authors have declared that no competing interests exist.Authors with competing interests Enter competing interest details beginning with this statement: I have read the journal's policy and the authors of this manuscript have the following competing interests: [insert competing interests here] * typeset Ethics Statement Enter an ethics statement for this submission.This statement is required if the study involved: /A" if the submission does not require an ethics statement.General guidance is provided below.Consult the submission guidelines for detailed instructions.Make sure that all information entered here is included in the Methods section of the manuscript.Ethical clearance was obtained from the Ethical Review Committee, Faculty of Allied Health Sciences, University of Ruhuna(No:59.11.2021).Informed written consent was taken from all participants.Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationFormat for specific study types Human Subject Research (involving human participants and/or tissue) Give the name of the institutional review board or ethics committee that approved the study • Include the approval number and/or a statement indicating approval of this research • Indicate the form of consent obtained (written/oral) or the reason that consent was not obtained (e.g. the data were analyzed anonymously) • Animal Research (involving vertebrate animals, embryos or tissues) Provide the name of the Institutional Animal Care and Use Committee (IACUC) or other relevant ethics board that reviewed the study protocol, and indicate whether they approved this research or granted a formal waiver of ethical approval • Include an approval number if one was obtained • If the study involved non-human primates, add additional details about animal welfare and steps taken to ameliorate suffering • If anesthesia, euthanasia, or any kind of animal sacrifice is part of the study, include briefly which substances and/or methods were applied • Field Research Include the following details if this study involves the collection of plant, animal, or other materials from a natural setting: Field permit number • Name of the institution or relevant body that granted permission • Data Availability Authors are required to make all data underlying the findings described fully available, without restriction, and from the time of publication.PLOS allows rare exceptions to address legal and ethical concerns.See the PLOS Data Policy and FAQ for detailed information.
Ethical clearance was obtained from the Ethical Review Committee, Faculty of Allied Health Sciences, University of Ruhuna (No: 59.11.2021).Informed written consent was taken from all participants after providing detailed information of purpose of the research study, advantages, results, confidentiality, and methods of the research.Confidentiality of all information was kept properly.The data were collected from 12 th July to 21 st July, 2022.
Sleep quality was assessed by Pittsburgh Sleeping Quality Index, which is the validated tool for Sri Lanka and it helps to assess sleep quality by using seven components of sleep process over a one month period.In present study, two-third of study subjects had good sleep quality during first trimester.Findings of this study are in agreement with Ethiopian study which was conducted among 415 pregnant mothers.Ethiopian study also has used similar study tool, Pittsburgh sleep quality index as present study.Another study in Finland which was carried out with 78 pregnant mothers has got almost similar results even though they used Basic experienced higher habitual sleep efficiency, sleep disturbances and significantly longer sleep latency than women in other two trimesters.Among major components of quality sleeping according to the PSQI, subjective sleep quality, sleep latency, habitual sleep efficiency and sleep disturbances showed that significant difference around three trimesters.It is expected that findings of this research would be helpful for health and social care policy makers when formulating guidelines and interventions regard to improving quality of sleep among pregnant women in Sri Lanka.It is recommended to plan that planning awareness programs and assess sleep quality throughout the pregnancy with the aim of enhancing the quality of sleep of pregnant women.Further, research team would like to recommend to develop a cross cultural validated tool to assess sleep quality among pregnant women in Sri Lanka.Since Sri Lanka has unique cultural believes.
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During the past month, how often have you taken medicine (prescribed or 'over the counter') to help you sleep?
st trimester with 3 rd trimester.Also there was no statistically significant difference between the global PSQI score with number of children, educational status, marital status, occupational status and BMI category (Table

Table 4 . Association of psychological disturbances and sleep quality 181
[8]]tuation of hormonal level throughout the body.Mainly, Melatonin hormone helps for improve sleep level by regulating the circadian rhythms of several biological functions, including the sleep-wake cycle.According to the present study, women in third trimester experienced higher score of global PSQI, subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbances and significantly longer sleep latency than women in other two trimesters.Further, good sleep quality had gradually decreased from first trimester to the third trimester.The findings are comparable with Taiwan study which was conducted with 400 questionnaire is validated tool for Sri Lanka which can be used to assess the anxiety of general population.Edinburgh Postnatal Depression Scale is the questionnaire which is widely validated tool was used to assess the level of depression among mothers.Results of this present study are in line with several studies[15]around the world.Poor sleep quality is experienced by more than a half of pregnant women who have possible depression of varying severity[10].These finding may be attributed to the hidden fear of the impending birth of the child in women who experience pregnancy for the first time.This might be enhance with cultural background in our country, some pregnancy related myths such as whole baby care process belongs to the mother, knowledge and experience level of senior members of a family about pregnancy.From this study, advanced maternal age, gestational age, prenatal depression and anxiety are detected to be determinants of sleep quality during pregnancy period.This finding was confirmed by a China study has found that the significant contributors of sleep quality for pregnant women were prenatal depression, age and gestational age[5].Also similar results has found in Ethiopian study mentioned that advanced age, increased gestational age and multiparty are found to be determinants of poor sleep quality in pregnant women[8].It is clear that our results are more similar to data published by other authors worldwide and may be an important voice in worldwide analysis of sleep quality during pregnancy.